Key Takeaways
-
Medicare doesn’t cover everything, and many essential services carry extra costs you’ll need to budget for.
-
Understanding when and where these gaps occur helps you avoid surprises and plan your coverage more effectively.
Why Medicare Gaps Matter More Than You Think
When you enroll in Medicare, you may assume your healthcare needs are fully covered. But the truth is, Medicare has significant gaps that can lead to high out-of-pocket expenses. These coverage gaps are not always discussed at the doctor’s office, even though they can have serious financial consequences. Unless you know what to look for, you may end up paying far more than expected for routine care, hospital stays, or prescription medications.
Understanding where Medicare stops short can empower you to explore supplemental options, compare plan choices, and prepare for potential health expenses.
Hospitalization Isn’t Fully Covered
Medicare Part A covers inpatient hospital care, but it’s not unlimited. You’re responsible for a deductible each benefit period — in 2025, that’s $1,676. After 60 days of inpatient care, daily coinsurance charges kick in:
-
$419 per day from days 61 to 90
-
$838 per day after day 90, using lifetime reserve days (only 60 available)
If you exhaust your lifetime reserve days, you could be responsible for all costs beyond that.
Also, if you’re held for observation and not officially admitted, you might not qualify for Part A coverage at all — leaving you with unexpected bills.
Skilled Nursing Facility Stays Have Time Limits
After a qualifying hospital stay of at least three days, Medicare Part A covers skilled nursing facility (SNF) care. However, it only covers up to 100 days per benefit period:
-
Days 1–20: Covered in full
-
Days 21–100: You pay $209.50 per day in 2025
After 100 days, you must cover all costs. And if your stay isn’t preceded by a qualifying inpatient hospital stay, coverage might not apply at all.
Routine Dental, Vision, and Hearing Care Are Excluded
Original Medicare doesn’t cover most dental procedures, eye exams for glasses, or hearing aids. These are often essential services, particularly as you age, yet they must be paid out-of-pocket unless you have additional coverage.
-
Cleanings, fillings, dentures, and tooth extractions: Not covered
-
Routine eye exams, lenses, or frames: Not covered
-
Hearing exams and hearing aids: Not covered
If you need any of these services regularly, the costs can add up significantly.
Prescription Drug Coverage Requires a Separate Plan
Medicare Part A and B do not include most outpatient prescription drugs. You need to enroll in a separate Part D plan or have another source of coverage. Even then, your medication expenses may include:
-
Monthly premiums
-
Annual deductible (up to $590 in 2025)
-
Copayments and coinsurance
Also, new in 2025, there’s a $2,000 annual cap on out-of-pocket costs for prescription drugs under Part D, which offers some protection — but only after you’ve spent significantly.
Medical Services Abroad Aren’t Covered
Medicare typically doesn’t cover care received outside the U.S. So, if you travel internationally, you’ll need to arrange for separate travel insurance that includes emergency health coverage. Without it, any medical emergency abroad will be fully your responsibility.
Long-Term Care Isn’t Covered by Medicare
Medicare doesn’t pay for most long-term care services, such as custodial care in a nursing home or assistance with activities of daily living (ADLs) like bathing or dressing. This is one of the most common misconceptions.
If you need extended care:
-
Medicare may cover short-term skilled care (like rehab after surgery), but not long-term residential care
-
Medicaid may assist, but only after you meet strict income and asset limits
Families often find themselves paying thousands of dollars out-of-pocket or exhausting assets to qualify for Medicaid support.
Preventive Services Aren’t Always Free
While Medicare does offer a wide range of preventive services, some come with conditions:
-
Your first “Welcome to Medicare” visit is free only if completed within 12 months of enrolling
-
Annual Wellness Visits are covered, but follow-up services might not be
-
Certain screenings may carry costs depending on your provider or frequency
It’s important to verify whether a test or procedure is truly preventive and how often Medicare will cover it.
Ambulance Services Often Come With Cost Sharing
Emergency transportation is partially covered by Medicare Part B. However, it’s not without cost-sharing:
-
20% coinsurance after meeting the Part B deductible ($257 in 2025)
-
Not all ambulance rides are considered medically necessary by Medicare
If Medicare doesn’t deem the trip necessary, you could be responsible for the full charge.
Durable Medical Equipment Can Be Costly
Medicare Part B covers certain durable medical equipment (DME), such as walkers, wheelchairs, and oxygen equipment. But it involves:
-
20% coinsurance after the Part B deductible
-
Supplier and prescription requirements
Not all equipment or suppliers are approved by Medicare. Using an out-of-network provider can increase your expenses.
Mental Health Coverage Has Specific Limits
Mental health services are covered, but not all types or settings qualify. For outpatient care:
-
You pay 20% coinsurance after meeting the Part B deductible
-
Services must be provided by Medicare-approved practitioners
For inpatient psychiatric care:
-
Covered under Part A, with a lifetime limit of 190 days in a psychiatric hospital
If you exceed this cap, Medicare will not cover further inpatient psychiatric facility care.
Home Health Services Can Be Denied
Medicare covers home health services under Part A and Part B, but only under strict conditions:
-
You must be homebound
-
Your doctor must certify medical necessity
-
The care must be intermittent (not full-time)
Failure to meet any of these criteria can result in denial of coverage, leaving you responsible for hiring and paying for services yourself.
Observation Status vs. Inpatient Status
Hospitals sometimes classify you as “under observation” even if you stay overnight. This can:
-
Prevent SNF coverage after discharge
-
Lead to higher out-of-pocket costs for hospital services
Being under observation means you’re considered an outpatient, which limits Medicare coverage and your cost protections.
Cost-Sharing Across the Board
Even when Medicare covers a service, you still face:
-
Deductibles (Part A: $1,676, Part B: $257 in 2025)
-
Coinsurance (typically 20%)
-
Copayments, depending on the service
You’re financially responsible for these unless you have supplemental coverage like a Medigap policy.
Your Doctor Might Not Mention All This
Most healthcare providers focus on clinical care, not financial details. They may:
-
Assume you’re aware of Medicare costs and gaps
-
Not know what’s covered outside their specialty
-
Refer billing questions to your insurer or Medicare directly
That means the responsibility to understand and fill these gaps falls on you.
What You Can Do About It
To protect yourself from these gaps:
-
Review your Medicare Summary Notice (MSN) regularly
-
Compare supplemental coverage options (like Medigap or retiree coverage)
-
Consider a standalone Part D plan if you take medications
-
Ask detailed billing and coverage questions before receiving services
-
Stay aware of enrollment periods to avoid penalties or lapses
Staying informed is your strongest defense against surprise costs.
Stay Ahead of Medicare Gaps With the Right Help
While Medicare provides essential health coverage, it isn’t a complete solution. The coverage gaps — from hospital stays to routine vision care — can impact your physical and financial well-being. Many of these gaps only come to light after you receive a bill. By understanding where the holes are and planning accordingly, you can make more informed choices about supplemental coverage, plan options, and medical services.
If you’re unsure what your plan does or doesn’t cover, reach out to a licensed agent listed on this website for expert guidance.
